Memorandum by the Socialist Health Association
PRIMARY CARE DENTAL SERVICE
The Socialist Health Association was founded
in 1930 to campaign for a National Health Service and is affiliated
to the Labour Party. We are a membership organisation with members
who work in and use the NHS. We include doctors and dentists and
other clinicians, managers, board members and patients.
Our members are involved in a wide variety of
consultation and involvement processes in health and social care.
We are particularly concerned that dental services are available
to all who need them and that they contribute to improved oral
health and reduce inequalities. This submission is made on behalf
of the Association. The sections relate to the issues identified
by the Health Select Committee.
In April 2006 PCTs were not, for
the most part, able to decide what dental services to commission
to meet locally identified local needs. They were, rightly, obliged
to offer contracts to existing dental practices based on the amount
of NHS activity and NHS earnings by the practice during the reference
year. This facilitated an element of stability for dental practices.
Overall some 4% of NHS capacity was
lost through practices refusing the new contract, although many
of the practices that rejected the contract were largely private
and had a comparatively small NHS base.
One of the advantages of the new
dental contract has been that if a dentist reduces his/her NHS
commitment, or "goes private", the funding is not lost
but is retained by the PCT which is then able to recommission
dental services to replace that which has been lost and it can
decide what services to provide to meet the needs (as opposed
to demands) identified in the local oral health needs assessment
and oral health strategy.
PCTs, however, realised early in
the year that the level of Patient Charge Revenue (PCR) that they
had been advised by the Department of Health that they could expect,
was not going to materialise. This seems to have been an error
in the calculations that the Department of Health had made in
setting the levels of patient charges, which were supposed to
provide the same income as the previous year ie a level playing
field. It had been made clear that it would be the PCT that carried
the risk if PCR fell short. This resulted in some PCTs deciding
not to recommission all of the lost capacity in order to offset
some of the shortfall in PCR.
Dental service utilisation is a classic
example of the inverse care law, where those with the greatest
oral health needs often receive less dental treatment than those
with much lower levels of need. Dental practices are frequently
concentrated in more affluent areas where dental needs are less
and private transport more available. The PCTs now have the opportunity
to commission services to provide a more equitable provision.
PCTs have had to build expertise
in commissioning dental services very rapidly and have succeeded
in doing so to varying extents. All PCTs should have regular oral
health needs assessments and produce oral health strategies as
the basis for commissioning plans. It is essential that all PCTs
have access to specialist dental public health advice in order
to commission services which are based on needs rather than just
demand and which will contribute to improving oral health.
Numbers of NHS Dentists and the Numbers of Patients
Registered with them
The number of dentists with an NHS
contract at the end of the first quarter (ie 30 June 2006) was
19,385, that is one dentist to 2,602 population. At the year end
(31 March 2007) there were 21041 dentists with an NHS contract,
a dentist to population ratio of 1:2397 (source NHS Information
Registration with an NHS dentist
was introduced in the early 1990s in order to pay dentists for
a continuing commitment, including out of hours cover, for patients.
The period of registration was initially up to two years but was
subsequently reduced to 15 months. The responsibility to provide
out of hours cover has now been transferred to PCTs and patients
no longer have NHS registration with a dentist, although dental
practices are encouraged to have their own lists of patients which
they consider are "their patients".
Recent guidance from the Institute
of Health and Clinical Excellence (NICE) has recommended that
six-monthly check-ups, which was appropriate when oral health
was poorer, was no longer appropriate for everyone and that dentists
should assess the best interval for individual patients according
to their needs and risk status. NICE recommended that the longest
interval between check-ups should be 24 months. Dental attendance
is now measured by the number and proportion of patients who have
attended a dentist within the previous 24 months.
As at 31 March 2006, a total of 28,144,599
patients had attended within 24 months (55.8% of the population).
At 31 March 2007, this figure was 28,097705 (55.7% of the population).
There had thus been a small reduction in the number of people
who had seen a dentist. However, bearing in mind the initial lost
capacity and the fact that it took a while to recommission the
lost service it might have been expected that a greater reduction
would have been seen. We would hope that there might be an increase
Although the proportion of adults
who had seen a dentist within 24 months fell from 51.7% to 51.5%
the proportion of children increase slightly from 70.6% to 70.7%
(Source NHS Information Centre).
Most dental practices have both NHS
and private patients, whilst a small number are exclusively NHS
or exclusively private. It is also possible for dentists to mix
NHS and private treatment in a single course of treatment, for
example to provide a white filling in a back tooth at the request
of the patient. We have no knowledge of the numbers of patients
Whilst we are content for patients
to chose to pay privately for treatment if they wish to do so,
we are concerned that some patients are "forced" to
pay privately, or join one of the private capitation type schemes,
because they think that they will be unable to receive dental
care under the NHS.
We support the continued development
of a team approach with the dentist leading a team of dental care
professional (dental therapists, dental hygienists, dental nurses
etc). Further developments of appropriate skill mix is supported.
TO NHS DENTAL
Most PCTs have established dental
advice lines to assist patients obtain NHS dental care. In most
PCTs there are adequate out of hours arrangements for patients
who need advice and/or treatment at night, weekends or Bank Holidays.
Many PCTs have commissioned urgent slots in dentists' appointment
books for patients who need urgent treatment and who do not have
a regular dentist. We commend such practice to PCTs that have
not already commissioned such arrangements.
We are concerned that the media reports
of large numbers of patients being unable to receive NHS dental
care does not accord with information from PCTs. One possible
reason for this dichotomy is that too many patients are unaware
of the PCTs' dental advice lines and are not making use of the
service established by PCTs to help them find an NHS dentist.
We are also aware that some PCTs have not updated the information
about available services on a regular basis. PCTs should do more
to publicise these services and ensure that the information available
to patients is kept up to date.
During the first year of the new
contract the PCTs have concentrated on ensuring that the quantity
of dental care was maintained. We are very strongly of the opinion
that it is essential that PCTs now give a greater emphasis on
the clinical governance / quality aspects of the service and how
this might best be performance managed.
Before April 2006 the UK had, probably,
the best database in the world of what treatment dentists carried
out. It is regrettable that the minimum data set now collected
from NHS dentists is now so minimal that PCTs only know what treatment
band of treatment has been provided. We understand that the Department
of Health is planning to require more information on the treatment
provided from April 2008.
One of the principles behind the
changes was to make NHS dental care more preventive oriented.
There is, however, no measurement of what preventive treatment
and advice is undertaken, although we understand that the expanded
data set from April will include information on the application
of fluoride varnish treatments.
The Department of Health, in conjunction
with the British Association for the Study of Community Dentistry,
has recently published a Prevention in Practice Toolkit, which
has been sent to all dental practices. It is essential that PCTs
monitor the extent to which practices include prevention in their
dental care. This must be part of the quality performance management
In May 2007 the Department of Health
published Smokefree and Smiling which set out guidance on how
members of the dental team should be involved in smoking cessation
activities, ranging from brief intervention advice (30 second)
and, where appropriate, referral to Stop Smoking Services by all
practices, to a higher level of individual advice where members
of the dental practice had undergone smoking cessation training.
PCTs need to monitor smoking cessation activities (and also advice
on chewing tobacco, which is common in some Asian communities,
and which is a major factor, together with excessive alcohol,
in causing oral cancer)
Dentists see patients who may not
go to their GP because they consider themselves to be healthy.
Some dental practices perform other health checking procedures
such as taking blood pressure. Consideration needs to be given
to whether this should be more common and how such additional
activities could be remunerated.
It must be recognised that the provision
of NHS dental care services is one aspect of improving oral health.
PCTs also need to provide or commission community based oral health
promotion programmes eg water fluoridation, other fluoride use
such as fluoride varnish programmes, fluoridated milk programmes,
dental health education programmes in schools, anti-natal sessions
etc. The successful implementation of such preventive programmes,
in conjunction with practice-based prevention will reduce the
future need for treatment.
The number of Units of Dental Activity
(UDAs) for which GDS dental providers were contracted to deliver
was based on the historical pattern of provision at that practice,
reduced by 5%. It was somewhat more complex for providers that
were previously Personal Dental Service Pilot practices as they
has already reduced the amount of treatment provided. Modern dental
practice puts emphasis on a minimal intervention approach ie to
do only what needs to be done and adopt a preventive approach
to reducing future dental disease.
Dentists who delivered the UDAs for
which they were contracted and paid had their contracts rolled
over. If the number of UDAs was 96% of the contracted level they
could agree with the PCT do have a contract that required the
same number of UDAs plus the shortfall from 2006-07. If they provided
less than 96% it was a matter for PCT / provider discussion whether
the PCT would reclaim the excess funding or whether additional
UDAs would be required in the current year.
Clearly the PCT has a duty to ensure
that the tax-payer receives what the dentists contract to deliver,
whilst at the same time being reasonable in understanding the
reasons why some practices under-performed and giving them the
opportunity to make up the shortfall. We are concerned that there
are anecdotal stories of some PCTs being unreasonable but it has
to be recognised that they are custodians of the public purse.
Those living in the most deprived
areas have, on average, much poorer oral health than those living
in more affluent areas. It needs to be recognised that practices
in areas with the most disadvantaged communities are likely to
have to provide more treatment within Bands 2 and 3 than practices
in richer suburbs. There are two ways of dealing with this differential.
One would be to divide Band 2 (3 UDAs) into two with more UDAs
awarded where a larger number of fillings needed to be provided
(patient charges could remain as they are or set at two differential
levels). However, it is already possible for PCTs to set the payment
to the dentist per UDA higher where dental needs are greatest
in order to recognise the greater amount of treatment that has
to be undertaken for each UDA. The expanded dataset to be introduced
from April 2008 will facilitate this process.
OF NHS DENTAL
As already stated most of the NHS
capacity that was lost through dentists rejecting the new contract
has now been replaced, and some PCTs have commissioned additional
capacity using some of their general funding. It is understood
that those PCTs that have sought tenders for replacement services
have had no shortage of interest. It is important that PCTs recognise
that the lowest bid may not provide good value for money if the
quality of the service they provide is poor. We have already stressed
the importance that needs to be given to further developing the
performance management of quality.
The three year transition period
ends in 2009. In order to maintain the confidence of the dental
profession it needs to made very clear, both by the Department
of Health and the PCTs, that NHS dental services will not suffer
a cutback when the ring-fencing of the dental budget ceases in
1. NHS Information technology
Dental practices are still not linked to the
NHS IT systems. Indeed not all dental practices are computerised.
This results, for example, in delays in dentists obtaining medical
histories from, and sharing information with, GPs when necessary,
delays in referrals to hospital from dentists, difficulty in PCTs
and others communicating with dental practices. Medical practices
have received financial assistance from the NHS to ensure that
they are integrated into the NHS IT systems. We believe that it
is important that dental practices are also part of the NHS electronic
2. Prison dental services
Over the past few years there has been an improvement
in the prison dental services. However, the level of service varies
from prison to prison. We recommend that Strategic Health Authorities
should performance manage the prison dental services in their
region and take steps to ensure that PCTs implement improvements
where the prison dental services do not match services generally
available to the community.
3. Water fluoridation
Mention has been made above to water fluoridation.
It is now over three years since parliament passed the fluoridation
clauses of the Water Act 2003 and yet only one PCT has asked its
PCT to undertake public consultation on implementing new fluoridation
schemes. Although there have been improvements in the general
level of dental health there remain totally unacceptable inequalities
with those in the poorest communities and those from certain ethnic
minority groups having the greatest amount of dental disease.
Fluoridation is the most effective community measure to improve
the dental health of children and adults, and in the medium /
long term will reduce the need for expensive dental treatment.
Ministers should ensure that all PCTs and SHAs review the need
for fluoridation without delay and, where the need for fluoridation
is established, use the new legislation to consult their local
communities on possible fluoridation proposals.